Key result
Intravascular imaging-guided PCI cuts major cardiovascular events ~33% vs angiography in complex coronary lesions.
Why the study?
Intravascular imaging-guided PCI has been associated with improved outcomes in complex coronary lesions, but recent randomized trials have reported conflicting findings.
Does intravascular imaging-guided percutaneous coronary intervention reduce major adverse cardiovascular events and cardiac death compared with angiography guidance in patients with complex coronary lesions?
Meta-Analysis (n=19,109)
Yes
Does intravascular imaging-guided percutaneous coronary intervention reduce major adverse cardiovascular events and cardiac death compared with angiography guidance in patients with complex coronary lesions?
Intravascular imaging guidance during PCI for complex coronary lesions significantly reduces MACE, cardiac death, MI, target lesion revascularization, and stent thrombosis compared to angiography alone, particularly when imaging-defined stent optimization is achieved.
Answers are grounded in this paper and cite their sources.
Supports intravascular imaging-guided PCI in complex lesions to reduce MACE and cardiac death; confirms benefits across 19 RCTs with optimization linked to lowest risk.
Background: Intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) has been associated with improved outcomes in complex coronary lesions; however, recent randomized trials have reported conflicting findings. We performed a comprehensive meta-analysis of randomized controlled trials (RCTs) to evaluate the impact of IVI guidance on clinical outcomes. Methods: We systematically identified RCTs comparing IVI-guided versus angiography-guided PCI in patients with complex coronary lesions. The primary outcomes were major adverse cardiovascular events (MACE) and cardiac death. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were estimated using random-effects models, with complementary Bayesian analyses. Prespecified subgroup and sensitivity analyses were performed. Results: Nineteen RCTs involving 19,109 patients were included. Compared with angiography guidance, IVI-guided PCI significantly reduced MACE (RR 0.67, 95% CI 0.55-0.83), cardiac death (RR 0.64, 95% CI 0.44-0.93), myocardial infarction (RR 0.86, 95% CI 0.75-0.99), clinically driven target lesion revascularization (RR 0.72, 95% CI 0.51-0.99), and stent thrombosis (RR 0.52, 95% CI 0.35-0.78). A significant interaction was observed by geographic region, with greater treatment effects among Asian trial populations (Pinteraction<0.01). Among studies reporting optimization outcomes, achievement of imaging-defined stent optimization was associated with substantially lower adverse event rates (RR 0.40, 95% CI 0.28-0.58). Conclusions: In patients undergoing PCI for complex coronary lesions, IVI guidance significantly reduces adverse cardiovascular events compared with angiography guidance alone. These findings suggest that the clinical benefit of IVI may be mediated, in part, through achievement of imaging-defined stent optimization.
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Akoum et al. (2026) conducted a meta-analysis in Complex coronary lesions undergoing percutaneous coronary intervention (n=19,109). Intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) vs. Angiography-guided PCI was evaluated on Major adverse cardiovascular events (MACE) and cardiac death (RR 0.67, 95% CI 0.55-0.83). Intravascular imaging-guided PCI reduced major cardiovascular events and cardiac death vs angiography guidance in complex coronary lesions.
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